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2008 Washington State MedicaidAging and Disability ServicesAdministration Chronic CareManagement ProgramClient Satisfaction Survey Results2008 Washington State Medicaid Aging and Disability Services AdministrationChronic Care Management Project Client Satisfaction SurveyA complete copy of this report is available at http://www.adsa.dshs.wa.gov/professional/hcs.htm.
Table of Contents Acknowledgments. 1 Introduction . 2 - 3Project BackgroundProject Goals How to Use This Report. 3 – 5PAM-13 activation stagesWhat do the bar graphs tell you?Statistical significanceLimitations Summary of Statistically Significant Results . 6 Bar Charts – Core Questions, CAHPS . 7 – 18RatingsHow people rate their health care .7How people rate their personal doctor or nurse .8How people rate the specialist they saw most often .9CAHPS CompositesGetting care without long waits . 10 - 13How well doctors communicate . 14 – 18 Bar Charts –Supplemental Questions, CAHPS . 19 – 31Your Personal DoctorHow often doctor talks about prevention . 19Does doctor understand how health affects daily life . 20How often doctor seems informed about care from other doctors . 21How often pain limits abilities . 22Does doctor understand impact of pain on life.23How often fatigue limits abilities . 24Does doctor understand impact of fatigue on life . 25Your SpecialistsMade appointments with specialist . 26How easy to get appointments with specialist . 27UtilizationHow many specialists seen . 28How many time visited personal doctor . 29How many times visited doctor’s office or clinic . 30Obtained care from doctor besides personal doctor . 31 Bar Charts – HEDIS Questions, CAHPS . 32 – 36Flu ShotHad flu shot . 32Tobacco useHow often smoke cigarettes . 33How often chew tobacco . 34Quit tobacco products . 35Reduced tobacco product use . 362008 Washington State Medicaid Aging and Disability Services AdministrationChronic Care Management Project Client Satisfaction SurveyA complete copy of this report is available at http://www.adsa.dshs.wa.gov/professional/hcs.htm.i
Bar Charts – Screener Questions for Chronic Conditions, CAHPS/DSHS . 37 – 40Seen doctor three or more times . 37Has condition that lasted at least three months . 38Takes prescription medicine . 39Ability to care for self compared to six months ago (DSHS) . 40 Bar Charts – Client Satisfaction Questionnaire (CSQ-8 ) . 41 - 48Quality of service . 41Service meets needs . 42Program meets needs . 43Recommend program to a friend . 44Satisfied with amount of help . 45Services help deal with problems . 46Rating service satisfaction . 47Return to program if needed . 48 Bar Charts – EQ-5D Health Status . 49 - 53Mobility . 49Self-care. 50Perform usual activities . 51Discomfort . 52Anxiety/Depression . 53 Bar Charts – Patient Activation Measures (PAM-13 ) . 54 – 67PAM-13 activation stage (composite of 13-items) . 54Responsible for taking care of own health problems . 55Active role is most important thing affecting health . 56Confident can help prevent health problems . 57Knows what prescribed medications do . 58Confident can tell when to contact doctor . 59Confident can tell doctor concerns . 60Confident can follow through on treatments at home . 61Understand health problems and causes . 62Knows available treatments . 63Ability to maintain lifestyle change . 64Knows how to prevent further problems . 65Confident can find solutions to new health problems . 66Confident can maintain lifestyle changes. 67 Bar Charts – Nurse Case Manager Questions (enrolled clients), DSHS . 68 – 72Has a nurse case manager . 68Nurse talks about managing pain . 69Nurse gives information to quit tobacco use . 70Information to quit smoking helped . 71How often nurse was helpful . 72 Bar Charts – Demographics Questions, CAHPS . 73 – 75Rate overall health . 73Age. 74Education. 752008 Washington State Medicaid Aging and Disability Services AdministrationChronic Care Management Project Client Satisfaction SurveyA complete copy of this report is available at i
AcknowledgementsThanks to the members of the Consumer Assessment of Healthcare Providers and Systems (CAHPS )survey workgroup who assisted with the development of the survey materials, the client brochure, and thestakeholder report.From the Aging and Disability Services Administration (ADSA): Candace Goehring, Unit Manager, Home and Community ProgramsDan Murphy, Office ChiefFrom the Health and Recovery Services Administration (HRSA): Shirley Munkberg, Acting Office Chief, Office of Quality and Care ManagementWe would like to thank:Qualis Health: Qualis Health, a health care quality improvement organization, coordinated the project, conducted theanalysis, assisted in development of the survey booklet, and developed this stakeholder report todisseminate the survey results.DataStat: Qualis Health coordinated with DataStat, Inc., a survey research organization located in Ann Arbor,Michigan, to collect the mail and telephone survey responses.Sincerely,Candace GoehringDan MurphyUnit Manager, Home and Community ProgramsOffice ChiefAging and Disability Services AdministrationAging and Disability Services Administration2008 Washington State Medicaid Aging and Disability Services AdministrationChronic Care Management Project Client Satisfaction SurveyA complete copy of this report is available at http://www.adsa.dshs.wa.gov/professional/hcs.htm.1
IntroductionThis report is designed to enable the Aging and Disability Services Administration (ADSA), WashingtonChronic Care Management Program vendors, and other organizations to monitor and evaluate theperformance of the Aging and Disability Services Administration Chronic Care Management Project. Aclient satisfaction survey was conducted and the responses of adults enrolled in Medicaid regarding theirexperiences with their health care services were analyzed. Medicaid recipients from each of the threeprogram groups—randomized to participate and successfully enrolled in the project (―Enrolled‖),randomized to participate but not successfully enrolled (―Not Enrolled‖), and randomized to the controlgroup—were surveyed and the results are presented here. Details of the survey administration, sampling,response rates, and weighting can be found in the Detailed Methodology Report.This report describes the background of the questionnaire, which includes questions from the MedicaidConsumer Assessment of Healthcare Providers and Systems (CAHPS ) survey, the 8-element ClientSatisfaction Questionnaire (CSQ-8), the 13-element Patient Activation Measure (PAM-13), the 5element EQ-5D, and questions developed by the WA Department of Social and Health Services (DSHS).A description of project goals and how to interpret the results is also included.Project BackgroundThis client satisfaction survey project used questions from 4 survey instruments: CAHPS survey, PAM13 , CSQ-8 , and EQ-5D. DSHS also included questions developed by department staff.The CAHPS survey tools were developed under cooperative agreements by Harvard Medical School, theRAND Institute, the Research Triangle Institute, and the Agency for Healthcare Research and Quality.HRSA has administered a version of CAHPS for various programs in Washington State for the past 12years, although this is the first year a CAHPS survey has been used for the King County Local ChronicCare Management Program. In CAHPS surveys, respondents provide information about their experienceswith of various aspects of medical care, including: Getting care that is neededGetting care without long waitsHow well doctors communicateHow people rated their health careHow people rated their personal doctor or nurseHow people rated the specialist they saw most oftenThe PAM-13 was developed at the University of Oregon Eugene by Judith H Hibbard, Eldon RMahoney, Jean Stockard, and Martin Tusler. The PAM-13 is constructed to measure the level of patientactivation in their own health care. The CSQ-8 was developed at the University of California SanFrancisco by Drs. Clifford Attkisson and Daniel Larsen in collaboration with Drs. William A. Hargreaves,Maurice LeVois, Tuan Nguyen, Robert E. Roberts, and Bruce Stegner. The CSQ-8 instrument isconstructed to measure general satisfaction with services received by individuals and families. The EQ5D is a widely used instrument to describe generic health status in terms of 5 dimensions: MobilitySelf-careUsual activitiesPain/discomfortAnxiety/depression2008 Washington State Medicaid Aging and Disability Services AdministrationChronic Care Management Project Client Satisfaction SurveyA complete copy of this report is available at http://www.adsa.dshs.wa.gov/professional/hcs.htm.2
Each dimension comprises 3 levels, indicating no problems, some or moderate problems, and extremeproblems. Assessing the percentage of enrollees who are in poor health or who have chronic conditionsis important to ensure adequate provider access, appropriate range of services, and financing for healthservices. Details of EQ-5D development and current status may be found online athttp://www.euroqol.org/.A copy of the 2008 survey instrument is included at the end of this report in Appendix A.Project GoalsThe primary goal of the Medicaid client satisfaction survey project is to provide timely information to theADSA, Washington Chronic Care Management Program to assist in evaluating the quality of the IntensiveChronic Care Management Program. This information was collected through mail and telephone surveysthat assessed clients' experiences with the health care and services they received through eitherstandard Medicaid services or, if enrolled, the Intensive Chronic Care Management Program.How to Use This ReportThis report is designed to allow the ADSA and other stakeholders to identify key opportunities to improveclients' health care experiences. This report includes data from two Medicaid subpopulations: thoserandomized to the Intensive Chronic Care Management Program (―Treatment‖), and those randomized toa control group. A total of 568 surveys (46.9%) out of a sample frame of 1,212 eligible enrollees metcompleteness criteria for inclusion in this report by answering at least 1 question in the survey.Results are displayed in a graphical format with 1 question per page. The first line of the page headingdisplays the program name (Aging and Disability Services Administration Chronic Care ManagementProject). The second line lists the question source (e.g., CAHPS, PAM-13 ). The third line is a briefdescription of the question category (e.g., Your Personal Doctor, Utilization, Flu Shot) along with thequestion number from the original questionnaire.PAM-13 Activation StagesBased on a national sample of 1,469, Insignia Health defined 4 stages of increasing patient activation asshown in the table below. A total is calculated for each respondent based on their responses to 13individual questions. A response of ―Strongly Disagree‖, ―Disagree‖, ―Agree‖, or ―Strongly Agree‖ isawarded 1, 2, 3, or 4 points, respectively. For items with a response of ―Not Applicable‖, the PAM rawscore is the respondent’s total score divided by the number of completed items and multiplied by 13. If therespondent did not respond ―Not Applicable‖ to any item, the total is the PAM raw score.2008 Washington State Medicaid Aging and Disability Services AdministrationChronic Care Management Project Client Satisfaction SurveyA complete copy of this report is available at http://www.adsa.dshs.wa.gov/professional/hcs.htm.3
PAM-13 Activation Stage DescriptionPercent ofNational Sample(n 1,469)PAM RawScoreActivationStage 47.0Stage 1May not yet believe that the patient roleis important11.8%47.1 to 55.1Stage 2Lacks confidence and knowledge totake action29.3%55.2 to 67.0Stage 3Beginning to take action36.5% 67.1Stage 4May have difficulty maintainingbehaviors over time22.3%DefinitionWhat do the bar graphs tell you?A series of bar graphs display survey results on pages 7-75. Each page represents results for 1composite question or one question using 2 bar graphs; 1 for the treatment and 1 for the control group.The number of clients answering each question is included as a footnote to each graph.Each bar graph is divided into 2-, 3-, or 4-response categories that represent the unadjusted percentresponse to 1 question or composite question for each subpopulation. The individual categories add up to100%, although sections for some graphs may not appear to add up to 100% because of rounding ofindividual sections for display. Some responses were recoded down to 3 or 4 categories for easier visualinterpretation. For example, the global rating scales of 0 – 10, the ―How often‖ scales of never,sometimes, usually, always, and the CSQ-8 scales of 4 levels of agreement were recoded for display as3 categories. Client age, educational level, and health care utilization questions were collapsed to 4categories. The "N/A" responses of the PAM-13 individual questions and ―don’t know‖ response towhether clients received a flu shot were ignored for display and statistical analysis. In no case did the―N/A‖ or ―don’t know‖ response exceed 10% of the total responses for either subpopulation.Statistical SignificanceStars were added to each bar chart in which the responses of clients in the treatment group weresignificantly different than the responses of clients in the control group. P-values less than or equal to0.05 were considered significant. The number of stars added corresponds to the level of significance.Please refer to the legend on the individual graphs for more specific details. When the treatment andcontrol group responses to a question were not statistically different from each other, no stars were addedto the bar charts.LimitationsPeople in worse health tend to report lower satisfaction and more problems with care than do people inbetter health. Older patients tend to report more satisfaction and fewer problems than do youngerpatients. There is some evidence that education level may affect scores as well, although the effects ofage and education are not as strong as health status. Therefore, differences in client satisfaction may bedue to sampling error or self-selection bias and not to differences in program quality or satisfaction.Additionally, there is potential response bias in the survey results. The accuracy of these findingsdepends on how well respondents represent the overall population under study. If the 46.9% of clientsthat responded to the survey are systematically different than the study population, then conclusionsdrawn here may be incorrect2008 Washington State Medicaid Aging and Disability Services AdministrationChronic Care Management Project Client Satisfaction SurveyA complete copy of this report is available at http://www.adsa.dshs.wa.gov/professional/hcs.htm.4
Finally, due to the study design, in which clients were randomized to the treatment and control groupsprior to enrollment in the program, an intent-to-treat analysis was performed. This means a largepercentage of those clients randomized to the treatment group (and analyzed as such) chose not to enrollin the program and therefore did not actually receive program services. If in fact the program waseffective at improving clients' health care experiences and satisfaction, this would dilute the programeffect and diminish the ability of this survey to detect statistically significant differences.2008 Washington State Medicaid Aging and Disability Services AdministrationChronic Care Management Project Client Satisfaction SurveyA complete copy of this report is available at http://www.adsa.dshs.wa.gov/professional/hcs.htm.5
Summary of Statistically Significant ResultsStatistically significant results of treatment and control group response comparisons are listed below.More clients in the treatment group reported: An overall rating of 7-8 for their personal doctor―Usually‖ getting an appointment at a doctor’s office or clinic as soon as they thought they needed itThat pain ―Never or Sometimes‖ limited their ability to do the things they needed to doHaving moderate pain or discomfortStrongly agreeing that they were responsible for taking care of their health problems.Having a ―Fair‖ overall health rating―No change‖ in their overall ability to care for themselves compared to 6 months agoThey had some problems with performing their usual activitiesResponses that classified them in PAM stage 3 ―Beginning to take action‖They ―agree‖ that they know how to prevent further problems with their healthThat they held a 4-year college degree or moreMore clients in the control group reported: An overall rating of 0-6 for their personal doctor―Never or Sometimes‖ getting an appointment at a doctor’s office or clinic as soon as they thoughtthey needed itThat pain ―Usually‖ limited their ability to do the things they needed to doVisiting their personal doctor ―10 or more‖ times in the last 6 monthsReducing their smoking or use of tobacco products in the past yearThey needed more help caring for themselves compared to 6 months agoThey were unable to perform their usual activitiesResponses that classified them in PAM stage 2 ―Lacks confidence and knowledge to take action‖They ―disagree‖ that they know how to prevent further problems with their healthThe highest level of education they had completed was ―some high school‖2008 Washington State Medicaid Aging and Disability Services AdministrationChronic Care Management Project Client Satisfaction SurveyA complete copy of this report is available at http://www.adsa.dshs.wa.gov/professional/hcs.htm.6
Aging and Disability Services AdministrationChronic Care Management ProjectConsumer Assessment of Healthcare Providers and SystemsCore: Question 7Results are based on 136 responses from the treatment group and 416 responses from the controlgroup to this question. When weighted these responses represent 266 and 911 individuals in thetreatment and control groups respectively.The results presented in this report are based on the 2008 Washington State Medicaid Aging and DisabilityServices Administration Chronic Care Management Project. The bar graphs show the weighted proportions forboth the treatment and control groups. Overall Chi square test results are noted for significant findings. Due torounding, some bars may not add to 100 percent.2008 Washington State Medicaid Aging and Disability Services Administration Chronic Care Management ProjectClient Satisfaction SurveyA complete copy of this report is available at http://www.adsa.dshs.wa.gov/professional/hcs.htm.7
Aging and Disability Services AdministrationChronic Care Management ProjectConsumer Assessment of Healthcare Providers and SystemsCore: Question 17******Treatment and control responses differ significantly at the p 0.05 level.Treatment and control responses differ significantly at the p 0.01 level.Treatment and control responses differ significantly at the p 0.001 level.Results are based on 131 responses from the treatment group and 416 responses from the controlgroup to this question. When weighted these responses represent 256 and 911 individuals in thetreatment and control groups respectively.The results presented in this report are based on the 2008 Washington State Medicaid Aging and DisabilityServices Administration Chronic Care Management Project. The bar graphs show the weighted proportions forboth the treatment and control groups. Overall Chi square test results are noted for significant findings. Due torounding, some bars may not add to 100 percent.2008 Washington State Medicaid Aging and Disability Services Administration Chronic Care Management ProjectClient Satisfaction SurveyA complete copy of this report is available at http://www.adsa.dshs.wa.gov/professional/hcs.htm.8
Aging and Disability Services AdministrationChronic Care Management ProjectConsumer Assessment of Healthcare Providers and SystemsCore: Question 31Results are based on 135 responses from the treatment group and 428 responses from the controlgroup to this question. When weighted these responses represent 264 and 937 individuals in thetreatment and control groups respectively.The results presented in this report are based on the 2008 Washington State Medicaid Aging and DisabilityServices Administration Chronic Care Management Project. The bar graphs show the weighted proportions forboth the treatment and control groups. Overall Chi square test results are noted for significant findings. Due torounding, some bars may not add to 100 percent.2008 Washington State Medicaid Aging and Disability Services Administration Chronic Care Management ProjectClient Satisfaction SurveyA complete copy of this report is available at http://www.adsa.dshs.wa.gov/professional/hcs.htm.9
Aging and Disability Services AdministrationChronic Care Management ProjectConsumer Assessment of Healthcare Providers and SystemsScreener Getting Care without Long Waits: Question 1Results are based on 133 responses from the treatment group and 412 responses from the controlgroup to this question. When weighted these responses represent 260 and 902 individuals in thetreatment and control groups respectively.The results presented in this report are based on the 2008 Washington State Medicaid Aging and DisabilityServices Administration Chronic Care Management Project. The bar graphs show the weighted proportions forboth the treatment and control groups. Overall Chi square test results are noted for significant findings. Due torounding, some bars may not add to 100 percent.2008 Washington State Medicaid Aging and Disability Services Administration Chronic Care Management ProjectClient Satisfaction SurveyA complete copy of this report is available at 0
Aging and Disability Services AdministrationChronic Care Management ProjectConsumer Assessment of Healthcare Providers and SystemsScreener Getting Care without Long Waits: Question 3Results are based on 133 responses from the treatment group and 416 responses from the controlgroup to this question. When weighted these responses represent 260 and 911 individuals in thetreatment and control groups respectively.The results presented in this report are based on the 2008 Washington State Medicaid Aging and DisabilityServices Administration Chronic Care Management Project. The bar graphs show the weighted proportions forboth the treatment and control groups. Overall Chi square test results are noted for significant findings. Due torounding, some bars may not add to 100 percent.2008 Washington State Medicaid Aging and Disability Services Administration Chronic Care Management ProjectClient Satisfaction SurveyA complete copy of this report is available at 1 pa
A copy of the 2008 survey instrument is included at the end of this report in Appendix A. Project Goals The primary goal of the Medicaid client satisfaction survey project is to provide timely information to the ADSA, Washington Chronic Care Management Program to assist in evaluating the quality of the Intensive Chronic Care Management Program.
